Apply for Interim Healthcare Leadership

Please complete the questions below then click 'Submit' to send your application for consideration. Fields with an asterisk (*) are required.

Title:Interim Healthcare Leadership
Company:TiER1 Healthcare
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Contact Information
* Preferred Name:
* Last Name:
* Address 1:
Address 2:
* City:
* State:
* Email:
Application Information
Referred By (if applicable):
If you were referred to TiER1, please let us know who introduced you
Employment Arrangement(s):
Please select employment arrangement options (select all applicable alternatives)
Cover Letter:
You can type in a Cover Letter or Copy/Paste from an existing document.
Healthcare Credentials
Education - Please Select All that Apply
Bachelor's Degree
Master's Degree
Doctorate Degree

Healthcare Specialties
Academic Medical Center
Accreditation & Regulatory Compliance
Allied Health
Ambulatory Healthcare
Behavioral Healthcare (Psychiatry)
Cancer Care (Oncology)
Cardiovascular Care (Heart & Vascular)
Centers for Medicare and Medicaid Services (CMS)
Children's Hospital
Critical Access Hospital
Department of Defense (DoD)
Diagnostic Imaging & Radiology
Disease Specific Care
Electronic Health Record (EHR)
Emergency Management
Emergency Medicine (ED)
Employee & Occupational Health
Environment of Care & Life Safety
Facilities Management
Home Care
ICD Coding and Documentation
Infection Prevention & Control
Intensive Care
Lean & Six Sigma
Maternal-Fetal Medicine
Medical Staff
Nursing Care Centers
Long Term Acute Care
Pain Management
Palliative Care
Patient Blood Management
Patient Safety
Peri-Operative Services
Physical & Occupational Therapy
Physician Practice Management
Population Health
Project Management (Agile, PMP)
Primary Care
Pulmonary & Respiratory Care
Rehabilitation Medicine
Revenue Cycle Management
Rural Health
Sports Medicine
Spanish Speaking
The Joint Commision (TJC)
Veterans Health Administration (VHA)
Women's Health
Wound Care

Certifications (other):
General Questionnaire
TiER1 Healthcare welcomes applications from experienced interim healthcare executives, directors, and managers to provide leadership at client organizations.
* Have you done interim or consulting work before?
Yes   No
* Are you willing to travel to rural/remote and urban locations?
Yes   No
What, if any, are your geographic limitations?
* Are you willing to be deployed fulltime for extended periods- 6 months or more?
Yes   No
* Compensation Expectations (please be specific):
Confirmation and Authorization
* I confirm that the facts submitted in this application are true and complete to the best of my knowledge. I understand that if employed, falsified information is cause for dismissal.:
Yes   No
* I authorize the investigation of statements and authorize employers listed above to give you any and all information concerning my employment.:
Yes   No
* Type name as authorized signature:
Voluntary Self-Identification of Disability CC-305
Voluntary Self-Identification of Disability
Form CC-305
OMB Control Number 1250-0005
Expires 01/31/2020
Why are you being asked to complete this form?
Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities.i To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.
If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.
How do I know if I have a disability?
You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.
Disabilities include, but are not limited to:
  • Blindness
  • Deafness
  • Cancer
  • Diabetes
  • Epilepsy
  • Autism
  • Cerebal palsy
  • Schizophrenia
  • Muscular dystrophy
  • Bipolar disorder
  • Major depression
  • Multiple sclerosis (MS)
  • Missing limbs or partially missing limbs
  • Post-traumatic stress disorder (PTSD)
  • Obsessive compulsive disorder
  • Impairments requiring the use of a wheelchair
  • Intellectual disability (previously called mental retardation)
Please select one of the options below:

Yes, I have a disability (or previously had a disability)
No, I don't have a disability
I don't wish to answer
* Signature
* Today's Date
Reasonable Accommodation Notice
Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.
i Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor's Office of Federal Contract Compliance Programs (OFCCP) website at
PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.
Equal Opportunity Employment
TiER1 Performance Solutions is an Equal Opportunity employer and does not discriminate on the basis of race, ancestry, color, religion, gender, age, marital status, sexual orientation, national origin, medical condition, disability, veteran status, or any other basis protected by law.

This information will be used for summary reporting and legal compliance only. Completion of this form is voluntary and the answers provided (or not provided) are not a consideration for employment opportunities or terms or conditions of employment.
I Choose Not to Respond
American Indian or Alaska Native (Not Hispanic or Latino)
A person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment
Black or African American (Not Hispanic or Latino)
A person having origins in any of the Black racial groups of Africa
Hispanic or Latino
A person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race
Asian (Not Hispanic or Latino)
A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
White (Not Hispanic or Latino)
A person having origins in any of the original peoples of Europe, North Africa, or the Middle East
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)
A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands
Two or More Races (Not Hispanic or Latino)
All persons who identify with more than one of the above races
I Choose Not to Respond
Veteran Status: (Please check all that apply)
Individual with a Disability
An individual with a disability is a person who has a physical or mental impairment which substantially limits one or more of such person's major life activities, or who has a record of such impairment.
Vietnam Era Veteran
A person who 1) Served on active duty for a period of more than 180 days, and was discharged or released therefrom with other than a dishonorable discharge, if any part of such active duty occurred - a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5,1964, and May 7, 1975, in all other cases; or 2) Was discharged or released from active duty for a service-connected disability if any part of such active duty was performed; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases.
Disabled Veteran
1) A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or 2) A person who was discharged or released from active duty because of a service-connected disability
War/Campaign/Expedition Veteran
A veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized
Armed Forces Service Medal Veteran
A veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order No. 12985. To identify the military operations that meet this criterion, check your DD Form 214, Certificate of Release or Discharge from Active Duty
Recently Separated Veteran
Any veteran during the three-year period beginning on date of such veteran's discharge or release from active duty in the U. S. military, ground, naval or air service.
I Choose Not to Respond

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